On November 21 and 22, staff representatives on the Joint Health Care Committee, Monique Musick and Gwenna Richardson, along with alternate Tamah Hayes, joined union representative committee members and UA administration in a two-day health vendor summit. The meetings with UA’s health plan vendors and agents explored ways that vendors can better collaborate and integrate services to meet the health and wellness needs of UA’s plan members.
The first day was spent entirely with Premera representatives. Premera is now offering a much broader range of coverage under the new plan design including pharmacy coverage, integrated health management, personal health support, medical travel program, 24-hour nurseline, website portal and a mobile application.
The following benefits will be discussed in order. Quick links have been provided to help navigate to specific areas of interest.
- Integrated Health Management/Case Management
- Personal Health Support
- Prior Authorization
- Web portal/Mobile Applications
- Medical Travel Support
- Best Doctors
- ComPsych Guidance Resources
- Program Integration
Premera Pharmacy [Back to top]
The change from Caremark to Premera for the pharmacy benefit, which went into effect July 2013, is one of the most noticeable changes for plan members. Pharmacy is the most used benefit with an 80% utilization rate. Premera has partnered with ExpressScripts, the nation’s largest pharmacy benefit manager.
David Testerman, a pharmacist with Premera, presented information on the benefit design, utilization reports, discount services, network coverage and specialty pharmacy coverage. The pharmacy and therapeutics committee at Premera meets quarterly to review new drugs, make value assessments to determine preferred drugs, research new generics and establish which drugs require prior-authorization.
Prior authorizations accepted under Caremark were carried over into the new plan, but because Premera has different standards and classifications, some members may be, or have been, asked to get prior-authorization for their prescription now when they didn’t in the past. Some drugs may have moved into a different co-pay tier level. Members should be aware that changes in drug classification is an unavoidable part of changing pharmacy benefit management.
The coordination of pharmacy and medical coverage can lead to reduced costs and optimize member health. Premera employs a medical review process—RationalMed— to make sure that members are receiving safe and proper medical care. Premera can potentially stop fulfillment of a prescription at the point of sale if it poses a risk based on other pharmacy or medical claims, such as an unsafe combination of drugs or a drug that is potentially harmful because of existing medical conditions. They also monitor controlled substance utilization and provide outreach and intervention if a member is over-using controlled substances, or using multiple doctors and pharmacists to fulfill pharmacy claims. In some cases they may limit a member to a single prescriber to deter possible abuse.
Specialty pharmacy utilization is growing at 18% per year. These are very expensive medications used to treat highly complex medical conditions such as multiple sclerosis, rheumatoid arthritis, and some cancers. Utilizers make up less than 1% of the population, but account for more than 20% of total pharmacy costs. Estimates project that by 2018 more than 50% of total pharmacy cost will be spent on specialty pharmacy claims. Prescriptions are carefully monitored to make sure that medications are being properly utilized. The pharmacists at Premera automatically review the ingredients in any compound medication costing more than $200 to ensure that all ingredients are safe and medically necessary. They provide members with these conditions clinical counseling services and telephonic support from trained professionals at therapeutic centers with expert knowledge of the medical conditions and treatments.
Express Scripts has one of the nation’s largest networks, which provides significant discount and rebate opportunities and efficient claims processing. The most significant savings come through the mail-order service, especially on name brand drugs. Mail order service takes into account Alaska’s climate. It was requested that the 90-day supply available through mail order be an option on location too for generic medications. The reason this request was made is that many plan members want to support their local pharmacy and still have the cost-savings associated with filling three months of a prescription at once. If enacted this would only be available for generic medications; the discounts for name brands via mail order is too significant to lose.
Nurseline Calls [Back to top]
The 24-hour nurseline was added in July, and has had pretty good utilization in the first quarter of implementation. This service allows members to call a nurse at anytime to ask advice or get answers to medical questions. The nurse on the line can help direct the caller to the right level of care. In 65% of the cases so far, a person wondering if they needed to go to the emergency room was re-directed to a different option. The number for the Nurseline (800-841-8343) is printed on the front of every member’s insurance card.
Integrated Health Management/Case Management [Back to top]
Premera’s integrated health management program includes healthy living tools on their website, personal health support coaching (formerly through Alere) health case management services, care transition management and coaching. Their follow-up case management support can help prevent return trips to the hospital and identify gaps in care. It is important to know that Premera does this, since otherwise an unsolicited call from the insurance company could be a little alarming. An example of this might be that a nurse calls after a major surgery or hospitalization to make sure that any questions have been answered, treatment is being followed, to discuss options and decisions ahead, and to address medical needs.
Personal Health Support [Back to top]
The personal health support service is an option for persons with one of five conditions that consume approximately 75% of healthcare resources and have a strong correlation between lifestyle and health: asthma, diabetes, heart failure, coronary artery disease and chronic obstructive pulmonary disease (COPD). Formerly this service was done through Alere, and anyone enrolled in their support program has been transferred over to Premera. Members are identified then stratified based on the severity of their condition and potential future risk. Licensed RN’s, behavioral health specialists and dieticians trained in health coaching and motivational interviewing work with participants in this voluntary program to help set care goals and remove barriers to optimal health. Once engaged with coaching, members’ co-payments for select generic medications for treating these five conditions are waived. Coaching includes receiving calls every 4 to 6 weeks, quarterly condition-specific newsletters and digital health coaching resources.
Prior Authorization [Back to top]
Beginning in July 2014, Premera will begin requiring prior-authorization for non-emergency procedures. This process will assure coverage before certain services are provided, help contain costs and ensure fast claim payment. Prior authorization also protects members from risk and harm by avoiding procedures that do not show a benefit. There will not be a penalty for members under this new policy, but physicians could face non-payment if they fail to contact Premera for prior-authorization. While new to UA’s plan, prior-authorization is standard on practically every other health plan, and is common practice for health providers.
Website, Mobile Applications and Other Resources [Back to top]
The Premera website and mobile application are great resources for plan members. Express Scripts has its own application too for tracking pharmacy claims and utilization. In addition, UA’s benefits website includes a lot of valuable information for plan members. If you have not yet downloaded the Premera and Express Script applications you should consider it now. It can help locate an in-network provider, track deductibles and more.
Vendor Summit 2013 [Back to top]
On the second day, all of UA’s health benefit vendors made presentations to the committee and thus to each other. Through this process of sharing and collaborating our plan partners can find better ways to work together.
Premera [Back to top]
The team from Premera opened the discussion. They did not repeat the presentation from the day before, but answered questions and discussed additional topics.
Premera is actively working to expand their network of contracted providers and address ways of further reducing plan costs. Alaska has the nation’s third highest cost of health care. Some regulatory issues that Premera is investigating include limits to the Usual and Customary Reimbursement (UCR) rates and a pay-to statute being introduced in the Alaska legislature. These measures strive to limit how much costs can rise. They are also working to train and educate referring facilities on our preferred air ambulance/medevac service. Premera has two in-network air ambulance services, LifeMed and Airlift North. But the market dominant Guardian Flight is often called first. The difference in cost can be over $100,000. By limiting the use of non-network providers, huge cost-savings can be achieved.
Medical travel support [Back to top]
Medical travel support, sometimes called medical tourism, is a new Premera offering that allows members to take advantage of lower costs outside for 17 specific procedures all considered safe for travel and demonstrate guaranteed cost avoidance. It is an elective process, requiring the member to initiate the process by calling customer service for approval. So far the volume of inquiry has been pretty low, indicating that further communication on this new benefit is needed.
Best Doctors [Back to top]
Cheryl Warren, account executive for Best Doctors described this virtual second opinion and expert referral service. Obstacles to effective care make second opinions common. Doctors may be rushed, unfamiliar with developments in treatment options, overlook some details, or make an error in their diagnosis, treatment or procedure recommendations. A professional second opinion ensures members have the right diagnosis and treatment plan. There are four main services offered by Best Doctors: Inter consultation— a confidential second opinion; Ask the Expert—an alternative to trying to find answers on the Internet; Find Best Doc— a referral service for specialists and health care providers; Digital records—a collection and digitization service of a member’s medical records. Best Doctors only deals with medical cases, not dental or behavioral health concerns.
If a plan member seeks a second opinion, they begin with a call to Best Doctors (866-904-0910) and set up an appointment. A team is assigned to the case, and the member authorizes the release of their medical records. The team gathers the relevant information and summarizes case. Then top-rated specialists review the case. They re-look at everything, including x-rays and other test results. The specialists then write a recommendation on whether the diagnosis, treatment plan or procedure recommendation are right. Through the team, they send their recommendation back and review them with member. The team is trained to help answer questions and provide information to the member. In the case that a different conclusion was made by the specialist, they offer advice for approaching the original doctor with the new information. In general doctors are accustomed to second opinions and are open to the advice of top specialists in their fields. The entire process may take 4 to 5 weeks for the records to transfer, be summarized, thoroughly reviewed and a new (or confirming) recommendation sent back to the member.
Best Doctors had 30 consultations for UA in the past year, and of them 23% had a change of diagnosis and 71% a change in treatment. In general, 60% of the time there is either a wrong diagnosis and/or treatment; it’s the biggest reason a second opinion service is so important.
VSP [Back to top]
Regular eye exams are an important part of medical care. Certain conditions, including diabetes and glaucoma, affect vision. Diabetes is the number one cause of vision deterioration. VSP, our vision care vendor, is setting up data sharing with Premera to help identify individuals whose medical claims indicate a potential correlation with vision deterioration due to an underlying chronic condition. In some cases VSP providers are the first to detect signs of chronic conditions.
There are three steps to VSP’s eye health management process: medical data collection, patient exam and condition report and exam reminder report. The medical data collection is used to generate the patient exam and condition report which provides HIPAA-compliant data on chronic conditions to the university. The data can help identify individuals who could be engaged in programs to help manage a chronic condition. The exam reminder report tracks follow up eye exam visits and sends reminders to members for important regular exams.
As part of a VSP benefit promotion, they will extend the frame/contact lens allowance by $20 starting Jan. 1. That will increase the allowance from $150 to $170. The average claim cost was $121.98 last fiscal year.
They want to drive members more to the website. There is low visitation by plan members. The Website includes frame styles carried by vision doctors in the area and other resources for members. Visit vsp.com for more information.
ComPsych [Back to top]
Shannon Reaska presented information on the employee assistance program (EAP) from ComPsych. ComPsych is working to break the notion that the EAP is just for psychological concerns and is actually a very comprehensive program providing guidance tools and resources on many family, legal, financial and wellness topics. Their website contains more than 80 free eBooks and 20 mobile apps on a wide range of helpful topics. That is in addition to the videos, podcasts resource guides and other media content available at their site GuidanceResources Online. There is very low utilization by our plan members of family services offerings. There is opportunity to enhance engagement in these services.
The GuidanceResources Program includes:
EAP services— Free short-term counseling, management referral, training/seminars, critical incident and stress management support services, management consultation
FamilySource— Unlimited referral and resources for: childcare, elder care, education, relocation, daily living issues, etc.
LegalConnect— Unlimited consultation with a ComPsych attorney, free 30 min consultation with a lawyer in your community, percent discount off services by a lawyer. Coverage for: parent rights, civil/criminal issues, divorce, etc.
GuidanceResources Online— thousands of articles on helpful topics, tools and calculators, videos on various topics, searches for lawyers, childcare, nursing homes, discount programs, helpful monthly email tip sheets
EstateGuidance— Online access to will documentation tools and simple to follow questions that work as a guide through the creation of a legally binding will
Onsite or online training workshops can be scheduled on a number of different personal development or work-life topics ranging from parenting, legal and finance, behavioral health and wellness. Visit guidanceresources.com, and enter the company web ID for the University of Alaska: GC5901Q. Or call 866-465-8934.
Healthyroads [Back to top]
UA’s newest vendor is Healthyroads. Their services are anticipated to roll out with Web access beginning in January and on-site implementation in February with onsite coaches available March 1. Full implementation of the program will be complete by July 1.
Healthyroads has been offering health coaching and wellness services for 12 yrs. The services they will be providing the university include online health improvement tools, biometric screenings, health risk assessments, and coaching services, including online, telephonic and onsite. The results will be used to help members identify individual ways to improve their health and generally build a healthier workforce.
The personal health assessment will integrate biometric data to give a more accurate picture of member health. Each plan member will have access to a comprehensive member portal with the results of their health assessment and educational resources to address health risks and help develop a health improvement plan. Their personal scorecard will be integrated into a personal action plan based on their risk profile. The scorecard will be updated as new data is received.
The Website Healthyroads.com contains far more than just the personal health improvement plans. They provide free health trackers for diet and exercise, online coaching courses, personalized SMS and/or email health tips, challenges and competitions, educational resources and a medical library. They also have mobile devices options for many of the trackers and services.
The personal health assessment will be used to identify and engage high-risk individuals into programs to help them improve their health through increased activity, nutrition, stress management weight loss, or tobacco cessation. All of this is done through a HIPAA safe process with no individual data disclosure to UA.
Healthyroads Lifestyle coaching program addresses four primary health risks: nutrition, exercise, tobacco use and stress management. The coaches all hold a minimum of a bachelor’s degree in a health-related field, and are overseen by senior-level coaches of registered dieticians, registered nurses, licensed medical professionals and other professional staff. Members work with one coach throughout the entirety of the program. Coaching will be available Monday through Friday 5 a.m. to 6 p.m. AKST and Saturday 6 a.m. to 3 p.m. Enrollment to the program can be done online or by phone. Phone-in coaching services will be available to employees anywhere in the system. In addition, onsite coaching will be available in Fairbanks, Anchorage and Juneau
In addition to personal, individual coaching services, there is a “ask-a-coach” service available to all eligible members featuring a secure online message box. Members can use this to ask general personal health questions from any of the Healthyroads coaches. The wellness program through Healthyroads will be available to all health plan enrolled employees and their spouses/partners.
Program Integration [Back to top]
The summit concluded with a brainstorming session on the integration of services. A key topic was “warm referrals”— or the process whereby one vendor suggests the services of another vendor. For example if a person enrolled in personal health coaching becomes diagnosed with a chronic condition, their Healthyroads coach can refer them to Premera’s Personal Health Support services with its associated waiver of maintenance drugs co-pays. Similarly they can refer members to employee assistance programs for additional resources to address underlying work-life conditions affecting stress and job performance.
Representatives from each company committed to meet together in January to further discuss better ways to integrate their services for the improved health of UA plan members.